The study of patient safety has come a long way in the past twenty years,1 and yet commentators argue that it still has a long way to go.2,3 The prevailing model assumes that patient safety is a linear process, promoting concepts from manufacturing industries that identify errors after they have occurred and proposing solutions in the hope that subsequent events will be amenable to the same solution.4 This model has been successful in areas where the problems are well-understood and controllable – checklists to prevent central line infections are one such example.5 Yet, patients across healthcare settings continue to experience preventable harms6 and, alarmingly, the incident rate has not changed for more than 50 years.7 This persistent rate of harm suggests that another approach to patient safety is needed.
Thus, it may be time to shift our thinking on patient safety from relying solely on expert-based science to also accounting for the action, deliberation, and learning that occur in the moment. Such a shift is necessary because of the rapid rise of the many drivers of care complexity, including chronic disease, multi-morbidity, polypharmacy, and the push for patient and family-centered care. This surge in general care complexity moves the center of gravity of safety from simple rules and stable evidence (the elegant mechanics of industrialized production) toward local adjudication and ad hoc learning. Simple rules and solutions may have been effective twenty years ago as the patient safety movement developed, but healthcare complexity means that now there are increased opportunities for safety failures.
Keeping patients safe in the current healthcare environment requires actions and behaviors on the part of front-line clinicians, who must navigate through chaos and uncertainty. In our increasingly complicated systems, ” now includes activities that prevailing safety paradigms have not acknowledged, and our stance is that it is time to bring such work in as a focus for patient safety. In fact, the title of this blog post specifically references a famous and often cited paper by Barley and Kunda, ‘Bringing Work Back In’,8 that alerted researchers to the need to look at work closely to understand its potential for change, rather than assume that change is always possible.
When viewed in this perspective, the work of a multitude of safety-decisive protagonists including frontline clinicians, administrators, patients, and families must be better understood because the work of all of them plays a role in the making of everyday care. For example, the patient who says to a nurse, “You say that this is the same medicine as what I take at home, but this pill is not the same color” is acting in the role of self-advocate and causes the nurse to pause in their work and consider if a medication error was made. The hospital administrator’s role in patient safety has also evolved over time and as a result, their “work” now often takes the form of making time every day to make rounds and chat with patients and family members.
Patient safety is thus accomplished by patients themselves and all those who do the work: that is, all those who provide care for and with them. Care complexity unfolds in the here-and-now, where our actions tangle with circumstances, resources, and others. Yet currently available patient safety models continue to leave unexplored, unexplained, and untended the moment-to-moment realities of how care is enacted and experienced. Patients and clinicians alike do not know in advance the circumstances in which care will be provided. Patients do not know how long they will be hospitalized, for example, or if their roommates will be either noisy or moribund. Clinicians do not know who on the care team might unexpectedly be absent from work on any given day and if, because of the absence, they will be working “short.” Circumstances such as these are rarely, if ever, brought into view as the basis for how clinicians can begin to rethink and reshape the work of providing care. Yet as every patient and clinician knows, a noisy roommate can make it difficult to hear what a physician is saying, and an understaffed shift can create a context in which errors are more likely to . By incorporating influences on immediate decision-making into the larger framework of patient safety, we may create practice change and, ultimately, improve patient safety.
We suggest that these local circumstances must be the main point of departure for the next steps in safety innovation. To move forward the science of patient safety, we need to engage with complexity at the level of immediate patient care, where the work of care deliberation, fast-feedback and the specifics of care practice meet. It is therefore critical that all healthcare workers account for and reflect on the work that they do in real-time. Clinicians do not just bring analytic knowledge, but also fast-feedback exchange and shared practical knowledge gained from their work. Clinicians’ knowledge therefore can be used to strengthen patient safety by creating opportunities for feedback and learning through reflexivity, or shared deliberation that enables clinicians to see and frame themselves, their practices, and circumstances in new ways, thus building the capacity for meaningful clinical practice change.9
There are several approaches that emphasize practice change using such wisdom of the group, and we mention two here. One is through co-design, which involves patients, clinicians, and those with other roles in healthcare (e.g., receptionist, environmental service worker) working together to design better experiences for all by sharing observations and experiences of care.10,11 Co-design focuses on designing healthcare services around patient experiences; it acknowledges that unexpected circumstances, unacknowledged conditions, and unintended consequences exist. Through joint sessions between healthcare service users and providers, any preconceptions about the service experience can be identified, and this information can help steer the conversation “from what should be to what is,” which helps decrease conflicting priorities and beliefs.12 From a co-design perspective, the appropriate way forward is therefore through shared deliberation between clinicians, patients, and family members.
A second source of practice change could be through video-reflexive ethnography (V-RE), which also uses shared deliberation. V-RE is a method and quality improvement strategy that starts when clinicians identify a clinical practice, some aspect of their work, that would benefit from closer examination.9 One example of a clinical practice might be the hand-off of a patient from the operating theatre to the intensive care unit. The identified clinical practice is video recorded, with video footage capturing events as they actually occur in real time, including their broader material and spatial context, their technological dimensions, as well as people’s relationships, emotions, and behaviors. This represents the “ethnography” portion of the method. V-RE further includes “reflexivity” sessions where those videoed watch short clips together to strengthen self-awareness, other-awareness, and context-awareness. These sessions offer opportunities to question and negotiate changes to existing care arrangements, assumptions, and how the work is carried out. Reviewing videotaped encounters incorporates the three interrelated components of active learning (intentional engagement, purposeful observation, and critical reflection).13 Invariably, and because even the most ordinary and taken-for-granted kinds of care now reveal themselves to be deeply complex, participants are alerted to assumptions, behaviors, and practical constraints they normally would treat as given. V-RE generates a forum where uncertainties, intuitions and deliberations enable clinicians, patients, and other stakeholders to inhabit care complexity.
In summary, the worldview of how to keep patients safe should continue to evolve to keep up with increases in care complexity and ongoing harms. Care complexity has now reached a point where it demands engagement and intelligence from those at the center of care: our entire healthcare teams and our patients. We need to pay attention to the actions that we all take as part of the work of healthcare and share guidance on how to keep patients safe. We call on clinicians and administrators with an interest in improving patient safety to join us on this journey by engaging with care in real-time and ‘bringing work back in.’ 8
–Dr. Milisa Manojlovich & Prof. Rick Iedema
Dr. Milisa Manojlovich (@mmanojlo) is a nurse scientist at the University of Michigan seeking to improve patient safety through improved interdisciplinary communication. Prof. Rick Iedema (@rick_iedema) is Director of the Centre for Team-Based Practice & Learning in Health Care at King’s College London, focusing on clinician collaboration and communication and in patient involvement in healthcare practice improvement.
1.Shekelle PG, Wachter RM, Pronovost PJ, Schoelles K, McDonald KM, Dy SM. Making Health Care Safer II: An Updated Critical Analysis of the Evidence for Patient Safety Practices; 2013.
2. Vincent C, Aylin P, Franklin BD, et al. Is health care getting safer? Br Med J. 2008;337 (Novem(7680):a2426.
3. Wears RL, Sutcliffe KM. Still Not Safe. Oxford University Press; 2020.
4. Braithwaite J, Wears RL, Hollnagel E. Resilient health care: Turning patient safety on its head. Int J Qual Health Care. 2015;27(5):418-420. doi:10.1093/intqhc/mzv063
5. Mheen PJM de, Bodegom-Vos L van. Meta-analysis of the central line bundle for preventing catheter-related infections: a case study in appraising the evidence in quality improvement. BMJ Qual Saf. 2016;25(2):118-129. doi:10.1136/bmjqs-2014-003787
6. Bates DW, Singh H. Two decades since to err is human: An assessment of progress and emerging priorities in patient safety. Health Aff (Millwood). 2018;37(11):1736-1743. doi:10.1377/hlthaff.2018.0738
7. Schimmel EM. The hazards of hospitalization. Ann Intern Med. 1964;60(1):100-110.
8. Barley SR, Kunda G. Bringing Work Back In. Organ Sci. 2001;12(1):76-95. doi:10.1287/orsc.184.108.40.20622
9. Iedema R. Creating safety by strengthening clinicians’ capacity for reflexivity. BMJ Qual Saf. 2011;20(Suppl 1):i83-6. doi:10.1136/bmjqs.2010.046714
10. Boyd H, McKernon S, Mullin B, Old A. Improving healthcare through the use of co-design. N Z Med J. 2012;125(1357):76-87. doi:10.1136/bmj.2.3683.276-c
11. Batalden M, Batalden P, Margolis P, et al. Coproduction of healthcare service. BMJ Qual Saf. 2016;25(7):509-517. doi:10.1136/bmjqs-2015-004315
12. Green T, Bonner A, Teleni L, et al. Use and reporting of experience-based codesign studies in the healthcare setting: a systematic review. BMJ Qual Saf. 2020;29(1):64-76. doi:10.1136/bmjqs-2019-009570
13.Muench J, Sanchez D, Garvin R. A review of video review: New processes for the 21st century. Int J Psychiatry Med. 2013;45(4):413-422. doi:10.2190/pm.45.4.k